PANY 322nd Scientific Meeting

Monday, February 27, 2006, 8:15 pm
Einhorn Auditorium, Lenox Hill Hospital, 131 E. 76th Street, NYC
Analytic Perspective on Post-Traumatic Stress Disorder
in Combat Veterans

Herbert H. Stein, MD
Faculty Member, NYU Psychoanalytic Institute; Clinical Assistant Professor, Dept. of Psychiatry, NYU School of Medicine; and Staff Psychiatrist, New York Harbor Healthcare System of the Department of Veterans Affairs, New York, NY

Discussant: Harold S. Kudler, MD *
Associate Clinical Professor, Dept. of Psychiatry and Behavioral Sciences, Duke University Medical Center; and Acting Chief Medical Officer, Veterans Integrated Service Network No. 6, Durham, NC

Summary
This paper is based upon extensive experience with combat veterans in a non-analytic clinical setting. The author has worked for many years with combat veterans at a local VA as the Director and primary psychiatrist for an outpatient PTSD team. He has seen literally thousands of combat veterans in consultation, group therapy, medication management and other contacts, some for many years. In essence, he has been a psychoanalytic observer in a non-psychoanalytic setting.

When he began working in this area, the author was impressed by the vividness of the intrusions of traumatic memory in dreams, “flashbacks” and unwanted bolts of memory. His working theory was one which was shared by many in the analytic community, that these phenomena were explained as an attempt at mastery of trauma. Over time, he has come to the conclusion that there is a far more parsimonious explanation for these phenomena. What is perhaps most characteristic of people who have spent extensive time in a combat zone is their hyperalertness and hyperreactivity. It appears that under conditions of significant trauma, human beings develop automatized mechanisms of protection. In that context, reminders of the original danger in the form of dreams, hallucinations and intrusive memories serve as a warning mechanism, a means of insuring that one’s guard will not be let down, even in the face of apparent safety and especially when we are most vulnerable, as in sleep.

The author has further come to understand the dynamics of combat veterans from a number of perspectives: 1) Combat trauma, which is often pervasive or recurring, induces intense affective states that remain after the soldier is out of the combat zone. The veteran must continually cope with such affective states, such as fear, rage and grief; 2) Combat, by its unusual nature, may create unusual mechanisms involving guilt. Veterans may develop splits in their superego, simplistically between a “war zone conscience” and a civilian conscience. This may result in pervasive guilt and self-destructiveness, an adoption of the war morality as a means of protecting oneself from such guilt, and reverberations between the two forms of conscience; 3) Combat frequently creates intense group dynamics that affect post-war object relationships; and 4) To fully understand a war veteran who has been in significant combat, we must take into account his entire history, including who he was when he entered the war zone, what specifically happened to him there and the vicissitudes of his post-war experience.

*By invitation